Discharge destination and patient-reported outcomes after inpatient treatment for isolated lower limb fractures.

OBJECTIVES: To examine the association between discharge destination (home or inpatient rehabilitation) for adult patients treated in hospital for isolated lower limb fractures and patient-reported outcomes. DESIGN: Review of prospectively collected Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) data. SETTING, PARTICIPANTS: Adults (18-64 years old) treated for isolated lower limb fractures at four Melbourne trauma hospitals that contribute data to the VOTOR, 1 March 2007 - 31 March 2016. MAIN OUTCOME MEASURES: Return to work and functional recovery (assessed with the extended Glasgow Outcomes Scale, GOS-E); propensity score analysis of association between discharge destination and outcome. RESULTS: Of 7961 eligible patients, 1432 (18%) were discharged to inpatient rehabilitation, and 6775 (85%) were followed up 12 months after their injuries. After propensity score adjustment, the odds of better functional recovery were 56% lower for patients discharged to inpatient rehabilitation than for those discharged directly home (odds ratio, 0.44; 95% CI, 0.37-0.51); for the 5057 people working before their accident, the odds of return to work were reduced by 66% (odds ratio, 0.34; 95% CI, 0.26-0.46). Propensity score analysis improved matching of the discharge destination groups, but imbalances in funding source remained for both outcome analyses, and for also for site and cause of injury in the GOS-E analysis (standardised differences, 10-16%). CONCLUSIONS: Discharge to inpatient rehabilitation after treatment for isolated lower limb fractures was associated with poorer outcomes than discharge home. Factors that remained unbalanced after propensity score analysis could be assessed in controlled trials.

Patterns and Predictors of Return to Work After Major Trauma: A Prospective, Population-based Registry Study.

OBJECTIVE: To characterize patterns of engagement in work during the 4-year period after major traumatic injury, and to identify factors associated with those patterns. BACKGROUND: Employment is an important marker of functional recovery from injury. There are few population-based studies of long-term employment outcomes, and limited data on the patterns of return to work (RTW) after injury. METHODS: A population-based, prospective cohort study using the Victorian State Trauma Registry. A total of 1086 working age individuals, in paid employment or full-time education before injury, were followed-up through telephone interview at 6, 12, 24, 36, and 48 months post-injury. Responses to RTW questions were used to define 4 discrete patterns: early and sustained; delayed; failed; no RTW. Predictors of RTW patterns were assessed using multivariate multinomial logistic regression. RESULTS: Slightly more than half of respondents (51.6%) recorded early sustained RTW. A further 15.5% had delayed and 13.3% failed RTW. One in 5 (19.7%) did not RTW. Compared with early sustained RTW, predictors of delayed and no RTW included being in a manual occupation and injury in a motor vehicle accident. Older age and receiving compensation predicted both failed and no RTW patterns. Preinjury disability was an additional predictor of failed RTW. Presence of comorbidity was an additional predictor of no RTW. CONCLUSIONS: A range of personal, occupational, injury, health, and compensation system factors influence RTW patterns after serious injury. Early identification of people at risk for delayed, failed, or no RTW is needed so that targeted interventions can be delivered.

Comparison of the performance of mental health, drug and alcohol comorbidities based on ICD-10-AM and medical records for predicting 12-month outcomes in trauma patients.

BACKGROUND: Many outcome studies capture the presence of mental health, drug and alcohol comorbidities from administrative datasets and medical records. How these sources compare as predictors of patient outcomes has not been determined. The purpose of the present study was to compare mental health, drug and alcohol comorbidities based on ICD-10-AM coding and medical record documentation for predicting longer-term outcomes in injured patients. METHODS: A random sample of patients (n = 500) captured by the Victorian State Trauma Registry was selected for the study. Retrospective medical record reviews were conducted to collect data about documented mental health, drug and alcohol comorbidities while ICD-10-AM codes were obtained from routinely collected hospital data. Outcomes at 12-months post-injury were the Glasgow Outcome Scale - Extended (GOS-E), European Quality of Life Five Dimensions (EQ-5D-3L), and return to work. Linear and logistic regression models, adjusted for age and gender, using medical record derived comorbidity and ICD-10-AM were compared using measures of calibration (Hosmer-Lemeshow statistic) and discrimination (C-statistic and R2). RESULTS: There was no demonstrable difference in predictive performance between the medical record and ICD-10-AM models for predicting the GOS-E, EQ-5D-3L utility sore and EQ-5D-3L mobility, self-care, usual activities and pain/discomfort items. The area under the receiver operating characteristic (AUC) for models using medical record derived comorbidity (AUC 0.68, 95% CI: 0.63, 0.73) was higher than the model using ICD-10-AM data (AUC 0.62, 95% CI: 0.57, 0.67) for predicting the EQ-5D-3L anxiety/depression item. The discrimination of the model for predicting return to work was higher with inclusion of the medical record data (AUC 0.69, 95% CI: 0.63, 0.76) than the ICD-10-AM data (AUC 0.59, 95% CL: 0.52, 0.65). CONCLUSIONS: Mental health, drug and alcohol comorbidity information derived from medical record review was not clearly superior for predicting the majority of the outcomes assessed when compared to ICD-10-AM. While information available in medical records may be more comprehensive than in the ICD-10-AM, there appears to be little difference in the discriminative capacity of comorbidities coded in the two sources.

The prevalence of pre-existing mental health, drug and alcohol conditions in major trauma patients.

Objective Capturing information about mental health, drug and alcohol conditions in injury datasets is important for improving understanding of injury risk and outcome. This study describes the prevalence of pre-existing mental health, drug and alcohol conditions in major trauma patients based on routine discharge data coding. Methods Data were extracted from the population-based Victorian State Trauma Registry (July 2005 to June 2013, n=16096). Results Seventeen percent of major trauma patients had at least one mental health condition compared with the Australian population prevalence of 21%. The prevalence of mental health conditions was similar to the Australian population prevalence in men (19% v. 18%), but lower in women (14% v. 25%) and across all age groups. Mental health conditions were more prevalent in intentional self-harm cases (56.3%) compared with unintentional (13.8%) or other intentional (31.2%) cases. Substance use disorders were more prevalent in major trauma patients than the general population (15% v. 5%), higher in men than women (17% v. 10%) and was highest in young people aged 25-34 years (24%). Conclusions Under-reporting of mental health conditions in hospital discharge data appears likely, reducing the capacity to characterise the injury population. Further validation is needed. What is known about the topic? Medical record review, routine hospital discharge data and self-report have been used by studies previously to characterise mental health, drug and alcohol conditions in injured populations, with medical record review considered the most accurate and reliance on self-report measures being considered at risk of recall bias. The use of routinely collected data sources provides an efficient and standardised method of characterising pre-existing conditions, but may underestimate the true prevalence of conditions. What does this paper add? No study to date has explored the prevalence of Abbreviated Injury Scale and International Classification of Diseases and Health Related Problems, Tenth Revision, Australian Modification (ICD-10-a.m)-coded mental health, alcohol and drug conditions in seriously injured populations. The results of this study show the incidence of mental health conditions appeared to be under-reported in major trauma patients, suggesting limitations in the use of ICD-10-a.m. to measure mental health comorbidities. What are the implications for practitioners? In order to achieve improvements in measuring mental health, drug and alcohol comorbidities, we suggest the use of a series of different diagnostic systems to be used in conjunction with ICD-10-a.m., such as medical record review and self-reporting as well as linkage to other datasets. When applied simultaneously, diagnosis and outcomes of mental health may be compared and validated across diagnostic systems and deviations in diagnoses could be more readily accounted for.

Return to Work and Functional Outcomes After Major Trauma: Who Recovers, When, and How Well?

OBJECTIVE: To describe the long-term outcomes of major trauma patients and factors associated with the rate of recovery. BACKGROUND: As injury-related mortality decreases, there is increased focus on improving the quality of survival and reducing nonfatal injury burden. METHODS: Adult major trauma survivors to discharge, injured between July 2007 and June 2012 in Victoria, Australia, were followed up at 6, 12, and 24 months after injury to measure function (Glasgow Outcome Scale-Extended) and return to work/study. Random-effects regression models were fitted to identify predictors of outcome and differences in the rate of change in each outcome between patient subgroups. RESULTS: Among the 8844 survivors, 8128 (92%) were followed up. Also, 23% had achieved a good functional recovery, and 70% had returned to work/study at 24 months. The adjusted odds of reporting better function at 12 months was 27% (adjusted odds ratio 1.27, 95% confidence interval [CI] 1.19-1.36) higher compared with 6 months, and 9% (adjusted odds ratio 1.09, 95% CI, 1.02-1.17) higher at 24 months compared with 12 months. The adjusted relative risk (RR) of returning to work was 14% higher at 12 months compared with 6 months (adjusted RR 1.14, 95% CI, 1.12-1.16) and 8% (adjusted RR 1.08, 95% CI, 1.06-1.10) higher at 24 months compared with 12 months. CONCLUSIONS: Improvement in outcomes over the study period was observed, although ongoing disability was common at 24 months. Recovery trajectories differed by patient characteristics, providing valuable information for informing prognostication and service planning, and improving our understanding of the burden of nonfatal injury.

Disability weights based on patient-reported data from a multinational injury cohort.

OBJECTIVE: To create patient-based disability weights for individual injury diagnosis codes and nature-of-injury classifications, for use, as an alternative to panel-based weights, in studies on the burden of disease. METHODS: Self-reported data based on the EQ-5D standardized measure of health status were collected from 29 770 participants in the Injury-VIBES injury cohort study, which covered Australia, the Netherlands, New Zealand, the United Kingdom of Great Britain and Northern Ireland and the United States of America. The data were combined to calculate new disability weights for each common injury classification and for each type of diagnosis covered by the 10th revision of the International statistical classification of diseases and related health problems. Weights were calculated separately for hospital admissions and presentations confined to emergency departments. FINDINGS: There were 29 770 injury cases with at least one EQ-5D score. The mean age of the participants providing data was 51 years. Most participants were male and almost a third had road traffic injuries. The new disability weights were higher for admitted cases than for cases confined to emergency departments and higher than the corresponding weights used by the Global Burden of Disease 2013 study. Long-term disability was common in most categories of injuries. CONCLUSION: Injury is often a chronic disorder and burden of disease estimates should reflect this. Application of the new weights to burden studies would substantially increase estimates of disability-adjusted life-years and provide a more accurate reflection of the impact of injuries on peoples' lives.

Outcomes of severe lower limb injury with Mangled Extremity Severity Score ≥ 7.

AIMS: Complex fractures of the femur and tibia with associated severe soft tissue injury are often devastating for the individual. The aim of this study was to describe the two-year patient-reported outcomes of patients in a civilian population who sustained a complex fracture of the femur or tibia with a Mangled Extremity Severity Score (MESS) of ≥ 7, whereby the score ranges from 2 (lowest severity) to 11 (highest severity). METHODS: Patients aged ≥ 16 years with a fractured femur or tibia and a MESS of ≥ 7 were extracted from the Victorian Orthopaedic Trauma Outcomes Registry (January 2007 to December 2018). Cases were grouped into surgical amputation or limb salvage. Descriptive analysis were used to examine return to work rates, three-level EuroQol five-dimension questionnaire (EQ-5D-3L), and Glasgow Outcome Scale-Extended (GOS-E) outcomes at 12 and 24 months post-injury. RESULTS: In all, 111 patients were included: 90 (81%) patients who underwent salvage and 21 (19%) patients with surgical amputation. The mean age of patients was 45.8 years (SD 15.8), 93 (84%) were male, 37 (33%) were involved in motor vehicle collisions, and the mean MESS score was 8.2 (SD 1.4). Two-year outcomes in the cohort were poor: six (7%) patients achieved a GOS-E good recovery, the mean EQ-5D-3L summary score was 0.52 (SD 0.27), and 17 (20%) patients had returned to work. CONCLUSION: A small proportion of patients with severe lower limb injury (MESS ≥ 7) achieved a good level of function 24 months post-injury. Further follow-up is needed to better understand the long-term trajectory of these patients, including delayed amputation, hospital readmissions, and healthcare utilization. Cite this article: Bone Joint J 2021;103-B(4):769-774.

Pre-injury health status of major trauma patients with orthopaedic injuries.

BACKGROUND: Pre-injury health status is an important determining factor of long-term outcomes after orthopaedic major trauma. Determining pre-injury health status of major trauma patients with orthopaedic injuries is also important for evaluating the change from pre to post-injury health status. OBJECTIVES: Describe pre-injury health statuses reported at three different time points (6, 12 and 24 months) after injury and compare these with Australian normative values; determine the agreement between pre-injury health status collected at multiple time points post-injury; and identify factors associated with reporting better pre-injury health status. MATERIALS AND METHODS: A registry-based cohort study was conducted. Major trauma patients with orthopaedic injuries captured by the Victorian State Trauma Registry with a date of injury from January 2009 to December 2016 were included. Pre-injury health status (measured using the EuroQol-Visual Analogue Scale (EQ-VAS)), reported 6, 12 and 24 months post-injury, was compared against Australian population normative values. The Bland-Altman method of comparison was used to determine the agreement between pre-injury EQ-VAS scores reported 6 to 12 and 6 to 24 months post-injury. Mixed effects ordinal logistic regression was used to determine factors associated with reporting better pre-injury health status. RESULTS: A total of 3,371 patients were eligible for the study. The median (IQR) pre-injury EQ-VAS score reported 6, 12 and 24 months post-injury was 90 (85-100) out of 100. Participants' pre-injury EQ-VAS scores reported 6, 12 and 24 months post-injury were significantly higher than Australian population normative values. Pre-injury EQ-VAS scores reported 6 months post-injury agreed with pre-injury EQ-VAS scores reported 12 and 24 months post-injury. A significant association exists between pre-injury health status and age, comorbidities, injury characteristics, socioeconomic status and pre-injury work status. CONCLUSIONS: People with orthopaedic major trauma have better pre-injury health compared to the general Australian population. Therefore, population-specific values should be used as baseline measures to evaluate orthopaedic trauma outcomes. Pre-injury health status values reported at three different post-injury time points were comparable. If conducting a retrospective pre-injury health evaluation, researchers need be aware of factors that influence self-reporting of pre-injury health status and the response shift that may happen due to encountering injury.

Physical Activity and Sedentary Behavior 6 Months After Musculoskeletal Trauma: What Factors Predict Recovery?

BACKGROUND: Physical activity is increasingly recognized as an important marker of functional recovery following fracture. OBJECTIVE: The objectives of this study were to measure sedentary behavior and physical activity 2 weeks and 6 months following fracture and to determine associated demographic and injury factors. DESIGN: This was an observational study. METHODS: Two weeks and 6 months following fracture, 83 adults who were 18 to 69 years old and had upper limb (UL) or lower limb (LL) fractures wore an accelerometer and an inclinometer for 10 days. We calculated sitting time, steps, moderate-intensity physical activity (MPA), and vigorous-intensity physical activity and conducted linear mixed-effects multivariable regression analyses to determine factors associated with temporal changes in activity. RESULTS: At 6 months versus 2 weeks after fracture, participants sat less, took more steps, and engaged in more MPA. Participants with LL fractures sat 2 hours more, took 66% fewer steps, and engaged in 77% less MPA than participants with UL fractures. Greater reductions in sitting time were observed for participants in the youngest age group and with LL fractures, participants with high preinjury activity, and participants who were overweight or obese. For steps, greater improvement was observed for participants in the youngest and middle-aged groups and those with LL fractures. For MPA, greater improvement was observed for middle-aged participants and those with LL fractures. LIMITATIONS: Although this study was sufficiently powered for the analysis of major categories, a convenience sample that may not be representative of all people with musculoskeletal trauma was used. CONCLUSIONS: Working-age adults with LL fractures had lower levels of physical activity 6 months after fracture than those with UL fractures. Older adults showed less improvement over time, suggesting that they are an important target group for interventions aimed at regaining preinjury activity levels.

Level of agreement between medical record and ICD-10-AM coding of mental health, alcohol and drug conditions in trauma patients.

BACKGROUND: Despite the reliance on administrative data in epidemiological studies, there is little information on the completeness of co-morbidities in administrative data coded from medical records. OBJECTIVE: The aim of this study was to quantify the agreement between the International Classification of Diseases, Tenth Revision, Australian Modification (ICD-10-AM) administrative coding of mental health, drug and alcohol co-morbidities and medical records in a severely injured patient population. METHOD: A random sample of patients (n = 500) captured by the Victorian State Trauma Registry and definitively managed at the state's adult major trauma services was selected for the study. Retrospective medical record review was conducted to collect data about documented co-morbidities. The agreement between ICD-10-AM data generated from routine hospital coding and medical record-based co-morbidities was determined using Cohen's κ and prevalence-adjusted bias-adjusted kappa (PABAK) statistics. RESULTS: The percentage of agreement between the medical record and ICD-10-AM coding for mental health, drug and alcohol co-morbidities was 72.8%, and the PABAK showed moderate agreement (PABAK = 0.46; 95% confidence interval (CI): 0.37, 0.54). There was no difference in agreement between unintentional injury patients (PABAK = 0.52; 95% CI: 0.42, 0.62) compared with intentional injury patients (PABAK = 0.36, 95% CI: 0.23, 0.49), and no change in agreement for patients admitted before (PABAK = 0.40; 95% CI: 0.30, 0.50) and after the introduction of mandatory co-morbidity coding (PABAK = 0.46; 95% CI: 0.37, 0.54). CONCLUSION: Despite documentation in the medical record, a large proportion of mental health, drug and alcohol conditions were not coded in ICD-10-AM. Acknowledgement of these limitations is needed when using ICD-10-AM coded co-morbidities in research studies and health policy development. IMPLICATIONS: This work has implications for researchers of drug and alcohol abuse; mental health; accidents and injuries; workers' compensation; health workforce; health services; and policy decisions for healthcare, emergency services, insurance industry, national productivity and welfare costings reliant on those research outcomes.

Ten-Year Incidence of Sport and Recreation Injuries Resulting in Major Trauma or Death in Victoria, Australia, 2005-2015.

BACKGROUND: Sports injuries that result in major trauma or death are associated with significant health care burden and societal costs. An understanding of changes in injury trends, and their drivers, is needed to implement policy aimed at risk reduction and injury prevention. To date, population-level reporting has not been available regarding trends in serious sport and recreation injuries anywhere in Australia over such an extended period, nor have any studies of this length captured comprehensive, long-term data on all sports-related major trauma internationally. PURPOSE: To describe the incidence of sport and active recreation injuries resulting in major trauma or death over a 10-year period (July 2005 to June 2015) in the state of Victoria, Australia. STUDY DESIGN: Descriptive epidemiological study. METHODS: All sport and active recreation-related major trauma cases and deaths in Victoria, Australia, over a 10-year period were extracted from the population-level Victorian State Trauma Registry and the National Coroners Information System. Poisson regression analysis was used to examine trends in the incidence of sport and active recreation-related major trauma and death. RESULTS: The 10-year study period entailed 2847 nonfatal major trauma cases and 614 deaths (including 96 in-hospital deaths). The highest frequencies of major trauma cases and deaths were in cycling, motor sports, and equestrian activities. The participation-adjusted major trauma and death rate was 12.2 per 100,000 participants per year over the study period. An 8% increase was noted in the rate of nonfatal major trauma (incident rate ratio [IRR], 1.08; 95% CI, 1.06-1.10; P < .001) and a 7% decrease in the death rate (IRR, 0.93; 95% CI, 0.90-0.97; P < .001). Significant increases were found in the rates of major trauma (including deaths) in equestrian activities, motor sports, and cycling. CONCLUSION: The death rate from sport and active recreation decreased by more than half over the course of 10 years in Victoria, while the rate of nonfatal major trauma almost doubled. This increase is largely attributable to equestrian activities, motor sports, and cycling. Study findings highlight the need to prioritize investments in the prevention of trauma in these activities.

Mortality, functional and return to work outcomes of major trauma patients injured from deliberate self-harm.

BACKGROUND: Self-harm and intentional injuries represent a significant public health concern. People who survive serious injury from self-harm can experience poor outcomes that negatively impact on their daily life. The aim of this study was to investigate a cohort of major trauma patients hospitalised for self-harm in Victoria, and to identify risk factors for longer term mortality, functional recovery and return to work. METHOD: 482 adult major trauma patients who were injured due to self-harm and survived to hospital discharge, and were captured by the population-based Victorian State Trauma Registry (VSTR), were included. For those with a date of injury from January 1, 2007 to December 31, 2013, demographics and injury event data, Glasgow Outcome Scale Extended (GOS-E) and return to work (RTW) outcomes at 6, 12 and 24 months post-injury were extracted from the registry. Post-discharge mortality was identified through the Victorian Registry of Births, Deaths and Marriages (BDM). Multivariable logistic regression was used to determine predictors of the GOS-E and RTW and survival analysis was used to identify predictors of mortality. RESULTS: A total of 37 (7.7%) deaths occurred post-discharge. There were no clear predictors of all-cause mortality. Overall, 36% of patients reported making a good recovery at 24 months. Older age (p=0.01), transport-related methods of self-harm (p=0.02), higher Injury Severity Score (p<0.001) and having a Charlson Comorbidity Index weighting of one or more (p=0.02) were predictive of poorer functional recovery. Of patients who were working or studying prior to injury, 54% reported returning to work by 24 months post-injury. Higher Injury Severity Score was an important predictor of not returning to work (p=0.002). CONCLUSION: The vast majority of major trauma patients who self-harmed and survived to hospital discharge were alive at two years post-injury, yet only half of this cohort returned to work and just over a third of patients experienced a good recovery.

Association between perception of fault for the crash and function, return to work and health status 1†year after road traffic injury: a registry-based cohort study.

OBJECTIVES: To establish the association between the patient's perception of fault for the crash and 12-month outcomes after non-fatal road traffic injury. SETTING: Two adult major trauma centres, one regional trauma centre and one metropolitan trauma centre in Victoria, Australia. PARTICIPANTS: 2605 adult, orthopaedic trauma patients covered by the state's no-fault third party insurer for road traffic injury, injured between September 2010 and February 2014. OUTCOME MEASURES: EQ-5D-3L, return to work and functional recovery (Glasgow Outcome Scale-Extended score of upper good recovery) at 12 months postinjury. RESULTS: After adjusting for key confounders, the adjusted relative risk (ARR) of a functional recovery (0.57, 95% CI 0.46 to 0.69) and return to work (0.92, 95% CI 0.86 to 0.99) were lower for the not at fault compared to the at fault group. The ARR of reporting problems on EQ-5D items was 1.20-1.35 times higher in the not at fault group. CONCLUSIONS: Patients who were not at fault, or denied being at fault despite a police report of fault, experienced poorer outcomes than the at fault group. Attributing fault to others was associated with poorer outcomes. Interventions to improve coping, or to resolve negative feelings from the crash, could facilitate better outcomes in the future.

Predictors of in-hospital mortality and 6-month functional outcomes in older adults after moderate to severe traumatic brain injury.

INTRODUCTION: Traumatic brain injury (TBI) is the single largest cause of death and disability following injury worldwide. While TBI in older adults is less common, it still contributes to significant morbidity and mortality in this group. Understanding the patient characteristics that result in good and poor outcome after TBI is important in the clinical management and prognosis of older adult TBI patients. This population-based study investigated predictors of mortality and longer term functional outcomes following serious TBI in older adults. METHODS: All older adults (aged>64 years), isolated moderate to severe TBI cases from the population-based Victorian State Trauma Registry for the period July 2005 to June 2007 (inclusive) were extracted for analysis. Demographic, injury event, injury diagnosis, management and comorbid status information were obtained and the outcomes of interest were in-hospital mortality, and the Glasgow Outcome Scale-Extended (GOS-E) score at 6 months post-injury. Multivariate logistic regression analyses were used to identify independent predictors of in-hospital mortality and independent living (GOS-E>4) status at 6 months. RESULTS: Of the 428 isolated, older adult TBI cases, the majority were the result of a fall (88%), male (55%), and aged>74 years (76%). The in-hospital death rate was 28% and increasing age (p=0.009), decreasing GCS (p<0.001) and injury type (p=0.002) were significant independent predictors of in-hospital mortality. Of the 310 patients who survived to discharge, 65% were successfully followed-up 6 months following injury. There was no difference between patients lost to follow-up and those successfully followed-up with respect to the key population indicators of age, gender, or head injury severity. Younger (<75 years) patients, and those with an SBP on arrival at hospital of 131-150mmHg, were at increased odds of living independently at follow-up. No patients with a GCS<9 had a good 6-month outcome, and most of them died. The survival rate for brainstem injury was also low (21%). CONCLUSION: In this population-based study, we found that age, GCS, brainstem injury, and systolic blood pressure were the most important factors in predicting outcome in older adults with an isolated moderate to severe TBI.